Complaint Investigation Report

Emergency Medical Services (EMS) were not able to provide a full report to the emergency room (ER) hospital staff regarding R1 having a black eye due to the facility staff having little to no information on it. 1/5 staff stated they went to the communication logs while EMS was at the residence and read them what information was available. LPA reviewed R1’s records which revealed R1 was diagnosed with the Flu on Friday February 7, 2025 and by Monday February 10th in the morning staff called 911 due to R1’s breathing and he had a black eye. R1 was admitted to the hospital from the ER and R1 stayed in the hospital from 02/10/2025-02/21/2025. During the review of the residence video surveillance R1 was shown to be in the living room on the floor and several times hit R1’s head on the floor, the video shows the staff placing pillows around R1 and later providing blankets to R1. The staff did make notes in the communication log that R1 had hit R1’s head on the floor and R1 was refusing to go to R1’s room, another note was made that R1 had a black eye, and photographs were sent to the Administrator. 5/5 staff interviewed said R1 would fight sleep often and R1 would become unstable and a fall risk due to R1 being so tired. R1 was not a head banger or have behaviors of head banging. Community Care Licensing did not get an incident report for the black eye and asked the facility about it and the facility sent over a late incident reporting the black eye and how it occurred. Due to poor communication and staff not reading the logs as soon as they come on shift the staff did not effectively communicate to the EMS the resident’s issues/needs at the time of the 911 call therefore the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.